Provider Demographics
NPI:1841632262
Name:WILLOUGHBY, LINDSEY (DMD)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3313
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:859-655-6148
Practice Address - Street 1:1401 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011
Practice Address - Country:US
Practice Address - Phone:859-655-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9335122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100267130Medicaid